Issues Regarding Sexuality   12  

Elaine E. Steinke

OVERVIEW

Sexuality is an innate quality present in all human beings and is extremely important to an individual’s self-identity and general well-being (Wallace, 2008). Sexuality is the expression of basic human needs that includes “intimacy, emotional expression, and love” (World Health Organization [WHO], 2010, p. 1). Moreover, it encompasses both gender roles and sexual orientation, and influencing factors include the “interaction of biological, psychological, cognitive, social, political, cultural, ethical, legal, historical, religious, and spiritual factors” (WHO, 2010, p. 4). Sexual health “requires a positive, responsible approach to sexuality and sexual relationships as well as pleasurable, safe sexual experiences that are free from coercion, discrimination or violence” (WHO, 2010, p. 1). Sexual health contributes to the satisfaction of physical needs; however, sexual contact fulfills many social, emotional, and psychological components of life as well. This is evidenced by the fact that human touch and a healthy sex life may evoke feelings of joy, romance, affection, passion, and intimacy, whereas despondency and depression often result from an inability to express one’s sexuality (Buttaro, Koeniger-Donohue, & Hawkins, 2014). When this occurs, sexual dysfunction, defined as impairment in normal sexual functioning during desire, excitation, and/or orgasmic phases of the sexual response cycle, may result (Steinke, 2014). There are several subtypes of sexual dysfunction, including delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature ejaculation, and substance/medication-induced sexual dysfunction (American Psychiatric Association, 2013).

It is frequently assumed that sexual desires and the frequency of sexual encounters begin to diminish later in life. In today’s youth-focused society, sexuality in the context of aging is often believed to be impossible and is not openly discussed. The 77 million baby boomers who were part of the sexual revolution now face an interesting paradox, in that “the ignorance, prejudice, and silence about sex and sexuality that they fought so hard to upend are still alive and well in old age” (Connolly et al., 2012, p. 43). Despite the negative stereotypes, sexual identity and the need for intimacy do not disappear with increasing age, and older adults do not morph into celibate, asexual beings. Physical intimacy is an important individual right, including in older age. Likewise, safety and protection from sexual abuse are key issues that are often underrecognized (Buttaro et al., 2014; Connolly et al., 2012). This presents both ethical and legal issues, and it is important for nurses to recognize the potential for sexual abuse in all older adults, and particularly in those who are less able to resist such abuses because of physical incapacity, psychological vulnerability, or cognitive impairment.

Recognizing that older adults have a need for physical intimacy and that many wish to remain sexually active as they age is essential in promoting sexual quality of life. In a study of 3,005 U.S. older adults, current sexual activity was reported in 73% of adults aged 57 to 64 years, 53% of adults aged 65 to 74 years, and 26% of adults aged 75 to 84 years (Lindau et al., 2007). Being sexually active has been associated with better health, higher sexual desire scores, and erectile function (Killinger, Boura, & Diokno, 2014).

BACKGROUND AND STATEMENT OF PROBLEM

Despite the persistence of sexual patterns throughout the life span, there is limited research and information to assist nurses assess or intervene to promote sexual health among older adults. Contributing to this disconnect is the lack of societal recognition of sexuality as a continuing human need and a factor that perpetuates lack of sexual assessment and intervention among the older population. Other factors impacting sexual health include the presence of normal and pathological aging changes; environmental barriers to sexual health; special problems of the older adult that interfere with sexual fulfillment, such as cognitive impairment; and comorbid conditions that may impair the ability to be sexually active. Although sexuality in aging has often been overlooked in general, some literature addresses sexual activity and sexual concerns across the adult life span for diagnoses such as heart disease and cancer. For example, two scientific statements from the American Heart Association are available to help nurses and other providers in sexual counseling of cardiac patients and their partners (Levine et al., 2012; Steinke et al., 2013). Although resources are available for selected medical conditions, the widespread adoption of sexual counseling in practice remains problematic.

Nurses’ Views Toward Sexuality and Aging

Nurses’ hesitancy to discuss sexuality with older adults has a significant impact on the sexual health of this population. Maes and Louis (2011) reported that only 2% of nurse practitioners (N = 500) always conducted a sexual history, and 23.4% never or seldom did so in patients aged 50 years and older, although most reported comfort and confidence in sexual history taking. Nurse practitioners expressed greater hesitancy to discuss sex with patients of the opposite sex, similar to a prior report of general practitioners (Gott, Hinchliff, & Galena, 2004). Besides the barriers of lack of time (59%), interruptions (30%), and limited communication skills, some nurse practitioners (21%) cited the inability to respond to issues that arose from sexual history taking, indicating that increasing providers’ knowledge may be an important strategy (Maes & Louis, 2011). Similarly, only 22% of general practitioners reported routine sexual history taking and 15.5% proactively asked patients about sexual dysfunction (Ribeiro et al., 2014). In contrast, a qualitative study evaluating transcribed audio recordings of 483 periodic health exam visits in adults aged 50 to 80 years by physicians revealed that about one half of visits included some discussion of sexual health, and the majority of these discussions was initiated by the physician (Ports, Barnack-Tavlaris, Syme, Perera, & Lafata, 2014).

General discomfort with discussing sexuality by nurses, lack of experience in assessment and management of sexual dysfunction among older adults, and lack of confidence (East & Hutchinson, 2013) often prevent nurses from addressing the sexual needs of this population. A disparity exists between nurses’ readiness and willingness to discuss sexual needs and concerns with clients (East & Hutchinson, 2013). Various factors influence sexual discussions such as lack of privacy, personal attitudes, and embarrassment. Although inadequate knowledge by nurses has been reported, a study of nurses’ attitudes and beliefs revealed that 92% of nurses understood the impact of diseases and treatment on sexual function, and nearly two thirds stated that they felt both comfortable and responsible for such discussions, but the majority did not discuss sexual concerns in practice (80%) and most lacked confidence (60%) to do so (Saunamäki, Andersson, & Engstrm, 2010). Moreover, the sexuality of older adults is generally excluded from sparse gerontological curricula, and sexual assessment is viewed as less important than other assessments (Dattilo & Brewer, 2005). A study of senior nursing students revealed that most had positive attitudes and acceptance regarding sexual expressions, but most were hesitant in regard to sexual counseling interventions (Huang, Tsai, Tseng, Li, & Lee, 2013). Without education and experience in managing sensitive issues around sexuality, health professionals are often not comfortable discussing sexual issues with older adults. Health care providers may lessen discomfort when addressing sexual issues by increasing their knowledge on the subject, practicing effective communication strategies to increase comfort in sexual discussions, and routinely introducing this dimension of health into routine assessment and management protocols.

Nurses’ understanding of sexuality should be broadened beyond that of a relationship between just men and women. Many clients within various health care systems are lesbian, gay, bisexual, and transgender (LGBT) adults, and these alternative sexual preferences require respect and consideration. Negative media portrayals and gender stereotying are pervasive not only in regard to older adult sexuality, but particularly for those who are gay (Garrett, 2014). In addition, those who are gay and living in rural areas may be further marginalized (Fenge & Jones, 2012). Nurses are in key positions as first-line care providers to focus on health promotion in those who are LGBT, and to proactively work to reduce and eliminate health care disparities and barriers. Health-promotion strategies should address the areas of HIV/AIDS; safe sex; hepatitis immunization and screening; alcohol use and substance abuse; sexually transmitted infections (STIs); physical abuse, anxiety, and depression; as well as wellness exams such as prostate, testicular, breast, cervical, and colon cancer (Lim, Brown, & Justin Kim, 2014). Prevention focused on heart health, physical fitness, tobacco cessation, and diet are important for all older adults.

Older adults in the United States who live with HIV/AIDS face considerable challenges, including stereotyping, prejudice, and discrimination related to real or perceived sexual orientation, and this contributes to anxiety, depression, and higher risk sexual behaviors (Cahill & Valadéz, 2013). Conversely, older gay men with a same-sex domestic or married partner have a more positive affect and less depression (Cahill & Valadéz, 2013). Proactive screening and assessment are critical in the older HIV population, as is effective management that includes treatment of any mental health conditions and comorbidities.

Normal and Pathological Aging Changes

The “sexual response cycle,” or the organized pattern of physical response to sexual stimulation, changes with age in both women and men. After menopause, a loss of estrogen in women results in significant sexual changes. This deficiency frequently results in the thinning of the vaginal walls and decreased or delayed vaginal lubrication, which may lead to pain during intercourse (Lobo, 2007; Syme, 2014). Additionally, the labia atrophies, the vagina shortens, and the cervix may descend downward into the vagina and cause further pain and discomfort. Moreover, vaginal contractions are fewer and weaker during orgasm, and after sexual intercourse is completed, women return to the prearoused stage faster than they would at an earlier age. The result of these physiological age-related changes in women is the potential for significant alterations in sexual health that have traditionally received little attention from research or individual health care providers. The pain resulting from anatomical changes and vaginal dryness may result in the avoidance of sexual relationships in order to prevent painful intercourse. In addition, the intensity of postmenopausal symptoms has been associated with greater disruption of sexual function, particularly for those with postsurgically induced menopause compared to natural menopause (Topatan & Yildiz, 2012).

Men also experience decreased hormone levels, mainly a gradual decline in testosterone, which has been associated with decreased frequency and weaker orgasms, a longer refractory period between erections, less forceful and reduced amount of ejaculate, and erectile dysfunction (Syme, 2014; Yeap, Araujo, & Wittert, 2012). Men may experience fatigue, loss of muscle mass, depression, and a decline in libido. As a result of normal aging changes, older men require more direct stimulation of the penis to experience erection, which is somewhat weaker as compared to that experienced in earlier ages. Declining levels of testosterone in the aging man has more far-reaching implications, having been associated with reduced sexual activity, frailty, atherosclerosis, vascular disease, insulin resistance, metabolic syndrome, cardiovascular events, and overall mortality, although further study is needed to establish causal relationships (Yeap et al., 2012). Frailty in an older population has been associated with impaired sexual functioning and distress, and erectile dysfunction (Lee et al., 2013), illustrating the importance of evaluating sexual health and sexual activity, as well as managing comorbid conditions with the goal of improving both overall and sexual health.

Bodily changes, such as wrinkles and sagging skin, may cause both older women and men to feel insecure about initiating a sexual encounter and maintaining emotionally secure relationships. Perceptions of body image and sexual self-esteem often influence sexual interest and sexual activity, perhaps even more so for women than men (Syme, 2014). In addition, attitudes, beliefs, and lack of knowledge contribute to misperceptions about sexuality, changes in sexual function, sexual risk taking, and prevention. Cultural influences on attitudes and beliefs are often grounded in Western beliefs that youth and beauty are of higher value, and that sexuality in older adulthood is nonexistent, shameful, or disgusting (Syme, 2014). Taken together, bodily changes and negative attitudes and beliefs serve to hinder sexual expression among older adults. As noted, the aging baby boomer generation has been at the forefront of promoting sexual expression from their youth; thus, a greater openness to the importance of sexual expression throughout one’s life may result, along with greater societal recognition of the role of sexual health promotion in overall health.

In addition to normal aging changes, both chronic illness and a number of medical conditions have been associated with poor sexual health and functioning in the older population. A study of 100 women with chronic illness presenting at internal medicine clinics, revealed that 65% had sexual dysfunction, including painful intercourse, reluctance to engage in sex, orgasmic problems, and sexual dissatisfaction. Predictors of sexual dysfunction included older age; menopausal; unemployed; and experiencing fatigue, sleep problems, and pain and weakness in extremities (Mollaoğlu, Tuncay, & Fertelli, 2013). Diabetic women treated with insulin were more likely to report problems with vaginal lubrication and orgasm than nondiabetic women (Copeland et al., 2012). In 200 men with type 2 diabetes mellitus, 60% had erectile dysfunction, which was significantly associated with older age, fasting plasma glucose, hemoglobin A1c (HbA1c), creatinine level, and systolic blood pressure (Sharifi, Asghari, Jaberi, Salehi, & Mirzamohammadi, 2012). In addition, significant predictors of erectile dysfunction were older age and taking calcium channel blocker medications.

Sexual dysfunction is prevalent in cancer survivors, with 41% reporting a decline in sexual function and 52% with altered body image (Averyt & Nishimoto, 2014). In colorectal cancer, rates may be higher because of the impact of surgery, radiation, and chemotherapy on sexual function. Changes in sensation, vascular scarring, decreased vaginal lubrication, urinary or fecal incontinence, erectile dysfunction, and symptoms, such as fatigue or nausea, may interfere with sexual function. In men with postradical prostatectomy, sexual dysfunction often includes erectile dysfunction, reduced sexual frequency, diminished sexual desire, and orgasmic difficulties; both psychoeducational and psychotherapeutic interventions have positively impacted coping and sexual function in several studies cited in this systematic review (Lassen, Gattinger, & Saxer, 2013).

The presence of depression among older adults impacts sexual health, in that depression often causes a decline in desire and ability to perform exacerbated by its treatment. Lee et al. (2013) found that men who were prefrail or frail had higher depression scores and more erectile dysfunction, and depression mediated almost half of the total effect related to frailty and sexual distress. In a systematic review, those with urgency urinary incontinence faced considerable challenges in maintaining sexuality and overall quality of life, impacting psychological well-being (anxiety and depression), daily activities, sexual function, and work productivity (Coyne et al., 2013). The presence of anxiety and depression should be assessed among older adults and considered for the impact of these emotional and psychological factors on sexual health (see Chapter 15, “Late-Life Depression” and Chapter 21, “Urinary Incontinence”).

Medications used to treat commonly occurring medical illnesses among older adults also impact sexual function. Two of the major groups of medications include antidepressants and antihypertensives. Selective serotonin reuptake inhibitors (SSRI) are commonly used to treat depression, and have been linked with sexual dysfunction, although this is likely underreported (Trenque et al., 2013). A meta-analysis of data extracted from 63 studies and more than 26,000 patients treated for major depressive disorder with second-generation antidepressants revealed that citalopram and paroxetine contributed to statistically significant higher risk of sexual dysfunction, whereas buproprion conferred lower risk of sexual dysfunction (Reichenpfader et al., 2014). Cardiac medications that contribute to sexual dysfunction include beta blockers (exception: nebivolol), cardiac glycosides, and diuretics, with mixed results in studies related to alpha blockers, angiotensin-converting enzyme inhibitors (ACEI), and calcium channel blockers; certain drugs exert a negative effect and others have a positive impact on sexual function in some studies (Nicolai et al., 2013). Overall, angiotensin receptor blockers (ARBs) and statins do not appear to contribute to sexual problems in most studies. Combinations of drugs may negatively influence sexual function, for example, those cardiac patients taking a beta blocker alone or in combination with an ACEI had greater than three times the odds of sexual dysfunction (Cook et al., 2008). In a small study of those with heart failure, the number of medications taken significantly negatively impacted sexual activity, particularly for those of older age, who used tobacco or alcohol, and had diabetes (Steinke, Mosack, Wright, Chung, & Moser, 2009).

Special Issues Related to Older Adults and Sexuality

Cognitively impaired older adults continue to have sexual needs and desires that may present a challenge to nurses. A review of older adults’ cognitive functioning and sexual behavior indicated that those older adults engaging in sexual activity tended to have better overall cognitive function; the ability to think abstractly may be important in continuing a sexual relationship (Hartmans, Comijs, & Jonker, 2014). Conversely, forgetfulness, poor decision making, and problems with cognitive sequencing may negatively affect sexual function. Hypersexuality appears to be rare among cognitively impaired elderly, and apathy or indifference toward sexual acitivty may be more prominent (Hartmans et al., 2014).

Continuing sexual needs often manifest in inappropriate sexual behavior. Sexual behaviors common to cognitively impaired older adults may include cuddling, touching of the genitals, sexual remarks, propositioning, grabbing and groping, using obscene language, masturbating without shame, aggression, and irritability. In a small study of 10 patients admitted to an inpatient geriatric psychiatric ward, right frontal lobe stroke was significantly associated with inappropriate sexual behaviors, illustrating that organic causes can contribute to these symptoms (Bardell, Lau, & Fedoroff, 2011). Inappropriate sexual behavior can also lead to elder abuse, and those most likely to be victims are those who are cognitively impaired, although research is limited and such behavior likely underreported (Rosen, Lachs, & Pillemer, 2010). Nurses have an ethical responsibility to be cognizant of the potential for abuse, and to report and intervene promptly to maintain the safety of the older adult victim.

Masturbation is a method by which cognitively impaired men and women may become sexually fulfilled. Nurses in long-term care facilities may assist older adults to improve sexual health by providing an environment in which the older adult may masturbate in private. Accurate assessment and documentation of the ability of cognitively impaired older adults to make competent decisions regarding sexual relationships with others while in long-term care are essential. If the resident has been determined to be incapable of decision making, then the health care staff must prevent the cognitively impaired resident from unsolicited sexual advances by a spouse, partner, or other residents.

Environmental settings may also influence sexuality among older adults. Normally, engaging in sexual intercourse occurs within the privacy of one’s bedroom; however, for some older adults, extended care facilities are the substitute for what one called home. Residents of extended care facilities state that many of the obstacles they face regarding their sexuality include lack of opportunity, lack of available partner, poor health, feeling sexually undesirable, and guilt for having these sexual feelings (Benbow & Beeston, 2012). In a study of Polish nursing home residents (N = 85), mutual respect and being able to depend on one’s partner were important relationship factors (Mroczek, Kurpas, Gronowska, Kotwas, & Karakiewicz, 2013). Those reporting sexual tension that occurred occasionally or once per week or less, relieved sexual tension through sexual contact with long-term partners, masturbation, watching erotic videos, walking, and engaging in diversionary activities. Sexual intercourse was reported by 34% of respondents (Mroczek et al., 2013) Negative staff attitudes and beliefs regarding residents’ sexual activity often interfere with the expression of sexuality in long-term care settings. Often, only married couples receive the privacy needed for sexual activity (Mroczek et al., 2013)

Health care providers are in a unique position to assess and manage HIV among the older population. The shift in focus of HIV/AIDS care is in managing this chronic condition and its related comorbidities. Negative attitudes and stereotypes often result in greater social isolation and lack of social support by family and friends, with the older adult often more reliant on formal care providers (Cahill & Valadéz, 2013). In addition, greater attention to sexual health education regarding HIV risk in the older population is needed among elders and health care providers.

ASSESSMENT OF THE PROBLEM

A model to guide sexual assessment and intervention is available and has been well used among younger populations since the 1970s. The Permission, Limited Information, Specific Suggestion, Intensive Therapy (PLISSIT) model (Annon, 1976) begins by first seeking permission (P) to discuss sexuality with the older adult. Because many sexual disorders originate in feelings of anxiety or guilt, asking permission may put the client in control of the discussion and facilitate communication between the health care provider and client. This permission may be gained by asking general questions such as “I would like to begin to discuss your sexual health; what concerns would you like to share with me about this area of function?” Questions to guide the sexual assessment of older adults are available on many health care assessment forms. The next step of the model affords an opportunity for the nurse to share limited information (LI) with the older adult. In the case of older adults, this part of the model affords health care providers the opportunity to dispel myths of aging and sexuality and to discuss the impact of normal and pathological aging changes, as well as medications on sexual health. The next part of the model guides the nurse to provide specific suggestions (SS) to improve sexual health. In so doing, nurses may implement several of the interventions recommended for improved sexual health, such as safe sex practices, more effective management of acute and chronic diseases, removal or substitution of causative medications, environmental adaptations, or need for discussions with partners and families. The final part of the model calls for intensive therapy (IT) when needed for clients whose sexual dysfunction goes beyond the scope of nursing management. In these cases, referral to a sexual therapist is appropriate.

Sexual assessments will be most effective using open-ended questions such as “Can you tell me how you express your sexuality?” “What concerns you about your sexuality?” “How has your sexuality changed as you have aged?” “What changes have you noticed in your sexuality since you have been diagnosed or treated for disease?” “What thoughts have you had about ways in which you would like to enhance your sexual health?” The loss of relationships with significant, intimate partners is unfortunately common among older adults and often ends communication about the importance of self to the person experiencing the loss. This greatly impacts the older adult’s sexual health. Asking the older adult about past and present relationships in his or her life will help to aid this assessment.

Barriers to sexual health should be assessed, including normal and pathological changes of aging, medications, and psychological problems such as depression. Moreover, lack of knowledge and understanding about sexuality, loss of partners, and family influence on sexual practice often present substantial barriers to sexual health among older adults. Nurses should assess for the presence of physiological changes through a health history, review of systems, and physical examination for the presence of normal and aging changes that impact sexual health. Older adults may view the normal changes of aging and their subsequent impact on appearance as embarrassing or indicative of illness. This may result in a negative body image and a reluctance to pursue sexual health. It is important for nurses to consider the impact of normal and pathological changes of aging on body image and assess their impact frequently.

As discussed earlier, there are a number of medical conditions that have been associated with poor sexual health and functioning including depression, cardiac disease, diabetes, stroke, osteoporosis, cancer, and chronic obstructive pulmonary disease (Hyde et al., 2010; Steinke, 2013). Effective assessment of these illnesses using open-ended health history questions, review of systems, physical examination, and appropriate lab testing will provide necessary information for appropriate disease management and improved sexual function.

Assessing the impact of medications among older adults, especially those commonly used to treat medical illnesses, such as antidepressants and antihypertensives, are essential. Potential medications should be identified by reviewing the client’s medication bottles and the client should be questioned about the potential impact of these medications on sexual health. If the medication is found to have an impact on sexual health, alternative medications should be considered. The older adult should also be questioned regarding the use of alcohol because this substance also has a potential impact on sexual response.

INTERVENTIONS AND CARE STRATEGIES

Following a thorough assessment of normal and pathological aging changes, as well as environmental factors, a number of interventions may be implemented to promote the sexual health of older adults. These interventions fall into several broad categories, including (a) education regarding age-associated change in sexual function, (b) compensation for normal aging changes, (c) effective management of acute and chronic illness effecting sexual function, (d) removal of barriers associated with difficulty in fulfilling sexual needs, and (e) special interventions to promote sexual health in cognitively impaired older adults.

Client Education

The most important intervention to improving sexuality among the older population is education. It is important to remember that sexuality was likely not addressed in formal educational systems as the older adults developed and was rarely discussed informally. Older adults may possess dated values that impact sexual action, freedom, and desires and lead to both sexual frustration and conflict. Masters (1986) reported in his seminal work on the sexuality of older adults that older women were raised to believe that when menstruation ceased, they would cease to be feminine. Knowledge is essential to the successful fulfillment of sexuality for all people.

The incidence of HIV and AIDS infection is rising among older adults, and 19% of those aged 55 years and older were living with HIV infection in the United States in 2010, with older adults often diagnosed later in the disease process (Centers for Disease Control and Prevention [CDC], n.d.). There were 2,500 new infections in this age group, with higher rates among men than women and variations among ethnicities. This underscores the significant risk of HIV transmission in the older age group and the need for effective teaching regarding safe-sex practices. Teaching about the use of condoms to prevent the transmission of sexually transmitted diseases is essential. In response to this rise in HIV cases and the presence of other sexually transmitted diseases, it is essential to provide older adults with safe-sex information provided by the CDC.

Compensating for Normal Aging Changes

Assisting older adults to compensate for normal aging changes related to sexual dysfunction will greatly lessen the impact of these changes on sexual health. Among women, the discussion of anatomical changes in sexual anatomy will help them anticipate these changes in sexuality. For example, atrophic vaginitis is often treated with topical or systemic estrogen therapy or dehydroepiandrosterone (DHEA; Buster, 2012), and increased vaginal dryness among women may require the use of artificial water-based lubricants or topical estrogen agents. In men, delayed response and the increased length of time needed for erections and ejaculations are among normal changes of aging, which older adults may not be aware of. When older adults understand the impact of normal aging changes, they then understand the need to plan for more time and direct stimulation in order to become aroused.

One of the most important preventive measures that older adults may undertake to reduce the impact of normal aging changes on sexual health is to continue to engage in sexual activity. In a study of midlife in older men and women across five countries, frequent kissing, cuddling, caressing, and partner touching significantly predicted sexual satisfaction, and sexual frequency was related to sexual satisfaction (Heiman et al., 2011). Planning for more time during sexual activities; being sensitive to changes in one another’s bodies; the use of aids to increase stimulation and lubrication; the exploration of foreplay, masturbation, sensual touch, and different sexual positions along with education about these common changes associated with sex and aging may help immensely. By doing so, changes in sexual response patterns are less likely to occur. Eating healthy foods, getting adequate amounts of sleep, exercising, using stress-management techniques, and not smoking are also very important to sexual health.

Effective Management of Acute and Chronic Illness

Effective management of both acute and chronic illnesses that impair sexual health is also important. Interventions that improve sexual health are frameworked within the current interventions to treat disease. In other words, effective disease management using primary, secondary, and tertiary interventions will not only effectively treat the disease but also result in improved sexual health. Consequently, better glucose control among diabetics enhances circulation and may increase arousal and sexual response. Appropriate treatment of depression with medication and psychotherapy will enhance desire and sexual response. Although treatment of depression may help to improve libido and sexual dysfunctions, such as orgasmic disorders, medications to treat depression often impact sexual function by lowering libido and causing orgasmic disorders. Choosing antidepressants with less impact on sexual function, when possible, is an important consideration. For example, mirtazapine supported normal sexual function at 6 months in patients with major depression and sexual dysfunction at baseline (Saiz-Ruiz et al., 2005), and has been successfully used in SSRI-related sexual dysfunction (Ozmenler et al., 2008). Antidepressants more likely to contribute to sexual problems are those in the drug classes of SSRIs or serotonin norepinephrine reuptake inhibitors (SNRIs; Clayton, Croft, & Handiwala, 2014). When considering medication within any class of drug for those older adults who continue to be sexually active, choosing a drug with less sexual side effects, or using the lowest dose of a medication with known sexual side effects may help support sexual function.

Phosphodiesterase-5 inhibitors (PDE5-I), such as sildenafil citrate (Viagra), vardenafil HCl (Levitra), tadalafil (Cialis), and avanafil (Stendra), play a significant role in the treatment of erectile dysfunction that occurs with aging and are effective and well-tolerated treatments (Huang & Lie, 2013). Low-dose PDE5-I on a continuing basis has benefited those with postradical prostatectomy, diabetes mellitus, or after radiotherapy (Huang & Lie, 2013). This may be useful when intermittent dosing of PDE5-I is not effective. As noted previously, a number of medications may adversely affect sexual function in the older adult. Thorough evaluation of prescribed and over-the-counter medications is important in providing optimal medication management with the least sexual side effects and in patient education.

Both older adults and nurses may be hesitant to discuss sexual problems so it is important for nurses to be proactive and bring up the topic of sex. A few targeted questions are often all that is needed to determine interest in sexual activity, sexual concerns, and sexual problems experienced, either related to medications or to a particular chronic disease. For example, a nurse might ask: “What concerns do you have about resuming sexual activity?” “How important is it for you to engage in sexual activity with your partner?” “What sexual activities are most important to you?” “Are there sexual activities that you have been unable to engage in?” and/or “Have you noticed any change in sexual desire that has affected your ability to be sexually active?” Asking these and similar questions is an important step in guiding management of sexual problems (also see Assessment of the Problem section for other suggested questions). Recognition of the continuing sexual needs of older adults among nurses is essential to ongoing dialogue about sexual problems.

Removal of Barriers to Sexual Health

One of the greatest barriers to sexual health among older adults lies with nurses’ persistent beliefs that older adults are not sexual beings. Nurses should be encouraged to open lines of communication in order to effectively assess and manage the sexual health needs of aging individuals with the same consistency as other bodily systems and treat alterations in sexual health with available evidence-based strategies.

An essential intervention to promoting sexual health in this population is to educate nurses regarding the continuing sexual needs and desires persisting throughout the life span. Education regarding older adult sexuality as a continuing human need should be included in multidisciplinary education and staff development programs. Educational sessions may begin by discussing prevalent societal myths around older adult sexuality. Nurses should be encouraged to discuss their own feelings about sexuality and its role in the life of older adults. Moreover, the development of policies and procedures to manage sexual issues of older adult clients is important throughout environments of care.

Environmental adaptations to ensure privacy and safety among long-term care and community-dwelling residents are essential. Arrangements for privacy must be made so the dignity of older adults is protected during sexual activity. For example, nurses may assist in finding other activities for the resident’s roommate so that privacy may be obtained or in securing a common room that may be used by the older adults for private visits. Call lights or telephones should be kept within reach during sexual activity and adaptive equipment, such as positioning devices or trapezes, may need to be obtained. Interventions, such as providing rooms for privacy and offering consultations for residents regarding evaluation and treatment of their sexual problems, are a few of the many ways this may be accomplished (Wallace, 2008).

Families are an integral part of the interdisciplinary team. However, for older couples, especially those in relationships with new partners, it is often difficult for families to understand that their older relative may have a sexual relationship with anyone other than the person they are accustomed to them being with. A family meeting, with a counselor if needed, is appropriate in order to help the family understand and accept the older adult’s decisions about the relationship.

Special Interventions to Promote the Sexual Health of Cognitively Impaired Older Adults

Cognitively impaired older adults continue to have sexual needs and desires but may lack the capacity to make appropriate decisions regarding sexual relationships. Accurate assessment and documentation of the ability to make informed decisions regarding sexual relationships must be conducted by the interdisciplinary team (Benbow & Beeston, 2012). If the older adult is not capable of making competent decisions, participation in sexual relationships may be considered abusive and must be prevented. On the other end of the spectrum, nurses should not attempt to prevent sexual relationships and may play an important role in promoting sexual health among older adults who are cognitively competent to make decisions regarding sexual relationships. In these cases, nurses should implement all necessary interventions to promote the sexual health of older adult clients.

Inappropriate sexual behavior, such as public masturbation, disrobing, or making sexually explicit remarks to other patients or health care professionals, may be a warning sign of unmet sexual needs among older adults. In these situations, a full sexual assessment should be conducted using clear communication and limit setting. Following this, a plan should be developed to manage this behavior while providing the utmost respect and preserving the dignity of the client. Providing an environment in which the older adult may pursue his or her sexuality in private may be a simple solution to a difficult problem. Nonpharmacologic management includes redirecting behavior, reorientation, adapting the environment, seating the resident making sexual advances in a different area during social gatherings, pants without zippers for male residents who tend to expose or fondle themselves in public, education and explanation that behavior is inappropriate, counseling, and using same-sex caregivers (Benbow & Beeston, 2012; Rosen et al., 2010). Supportive strategies include encouraging family members to hug, kiss, and hold hands with their loved one, and the use of pets for sensory stimulation (Rosen et al., 2010). Medication management might be considered, and it includes antidepressants, antipsychotics, anticholinesterases, and anticonvulsants after first evaluating the benefit versus risk (see Chapter 20, “Reducing Adverse Drug Events”). In addition, supportive management in an institutional setting is crucial. Having established policies regarding sexual behavior for those who are cognitiviely intact as well as those who are cognitively impaired, an environment that facilitates open discussion, and education and support of staff are clearly important strategies (Benbow & Beeston, 2012).

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